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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTM <br /> 600 East Main Street, Stockton,CA 95202_ 29 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name:1 ::5- z'%� <br /> Page Z of v <br /> Facility Address: City: Inspection Date- <br /> 21170-9 <br /> ate:7 ! o-P <br /> FA#: PR#: Program lenient: <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum >1320 gallons in tanks and containers over 55 gallons. <br /> —/ Complete one box for each tank or each cumulative container product type. <br /> Tank(2820) ❑ Containers (2821) #of Containers: TAll <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: <br /> Total Capacity: / 12p(j gallons Install Date: <br /> (per or cumulative for containers by product type) <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: D5'l(p 7 <br /> (>250 gallons) (>55 gallons and<250 gallons) v <br /> 2 Product Type: A 4Q , <br /> Total Capacity: Z gallons T� <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ® Containers (2821) #of Containers: TAM 4V,5-1 112 Le zz 7 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: ST—gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) Containers (2821) #of Containers: TAM Q,5-/ le le &I <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 ` Product Type: i 0 <br /> Total Capacity: ,``"� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 153f gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />